2018 MIDTERM ELECTION

Time: D H M S

FINAL UPDATE: Reporter accuses wrong person of...discussing legitimate & reasonable concerns.

SEE IMPORTANT UPDATES AT BOTTOM.

Chris Jennings is a respected healthcare policy expert who worked for the Clinton administration for over 6 years and more recently worked for President Obama for a brief stint from 2013 - 2014. Neera Tanden is the President of the Center for American Progress, but before that she was a policy advisor for Hillary Clinton's 2008 campaign. Lee Fang is an investigative journalist for The Intercept whose work has been published and referenced in numerous respected national publications.

Unfortunately, Mr. Fang made a rather embarrassing false accusation the other day which he has yet to correct. [edit: see updates below]

After Scott Brown won in his election, Neera emails Hillary about secret plan to basically destroy health reform https://t.co/An008xLDjz

— Lee Fang (@lhfang) February 27, 2016

This tweet is shameful [edit: ok, that's a bit too strong...how about "silly"] for at least two reasons.

First of all, as Ms. Tanden pointed out this morning, the email sent to Sec. Clinton wasn't from her, but from Chris Jennings, as clearly noted in the "From" field. Ms. Tanden's name isn't even mentioned in the email in question.

Secondly, if you read the email itself (sent by Chris Jennings to Hillary Clinton on January 22, 2010, a few days after Republican Scott Brown won the special election to replace Ted Kennedy in the Senate), what it really amounts to is a sober overview/debriefing of just how incredibly fragile the healthcare reform situation was at the time, laying out the existing and potential pitfalls which the Obama administration faced going forward.

I've laid out the email in full below, highlighting key points, but to me, this hardly looks like Mr. Jennings (not Ms. Tanden) is "secretly planning to destroy health reform" whatsoever; he's simply pointing out the realistic hurdles which would have to be overcome if they don't pursue meaningful reform.

In fact, if you actually read the email, Jennings was arguing in favor of pushing through the ACA as opposed to nothing getting done at all. Why on earth this reflects negatively in any way on either Mr. Jennings, Ms. Tanden or Sec. Clinton, I have no idea:

I am well aware we don't have a lot of good options here. However, for a number of reasons, I am not at all confident that Rahm is making the right call about pushing for an incremental fall-back (although some tell me he has not made a final decision about whether to go small ball and, if so, how best to proceed). At the very least, he may be making a premature course change. As you know more than anyone, going incremental creates as many policy problems as it solves. Politically, we have a myriad of problems too:

Constructing an incremental package -- for which there is no consensus now on what that would be -- takes time and distracts attention from what the Dems want to be talking about -- jobs and the economy. The stakeholders that have agreed to cuts for comprehensive care will renege on the savings produced if it is for small ball (that does not significantly reduce their uncompensated care burden). The public, who will be told that they are getting insurance reform, won't get much (because you can't do guarantee issue and secure the elimination of pre-existing conditions for all people UNLESS you have near universal coverage and/or significant subsidies) and it will not take too long for them and the media to figure that out. (It is the one thing that the press has learned from this debate -- starting from your primary campaign debate over the individual requirement). And it will be extremely difficult to find a viable legislative vehicle that won't be slowed up and eventually killed by the Republicans with poison pills galore. They certainly aren't going to give the Administration a signing ceremony if they can prevent it. Can you imagine what would happen if the Administration had what was viewed as two separate failures at health reform in one Congress?

Moreover, as we both painfully know, any health reform failure will mean that the Republicans will be the writers of history (because the victors -- not the vanquished get the pen and the paper to do so). They will get to define what was in it and why it died. And this will have implications not just about the past but the future. Republicans will say more effectively that, given the chance, the Democrats will be right back at it again with their "evil, secret fantasy to take over the health care system." They will more successfully (and inaccurately) define "it" as being a deficit busting, government take-over that will ration care and harm seniors.

I know we are all panicked about the MA race and its implications -- all with just cause. But I think we need to step back and take a breath. We can't over-read the race, which every pollster I have talked to say is not a clean, slam on comprehensive reform. The public still wants change and action in this arena.

And the House can still pass the admittedly flawed Senate but relatively decent bill if we can convince the House that it is in their best interest to do so. (It will likely take some help from the Senate leadership and some changes in a subsequent reconciliation protected legislative vehicle to fix the most problematic provisions, but this can be done). If the House does pass the Senate bill, it is important to note that there are a lot of good things to sell even THIS YEAR including: the elimination of pre-existing conditions for children, the elimination of lifetime caps, the extension of dependent coverage for kids, the provision of small business tax credits or the first down-payment on the elimination of the so-called Medicare prescription drug "doughnut hole."

I have to admit that this will be difficult because the House is so angry and scared; they are furious with the White House and the Senate. As such, it is true that that they might well let their anger cloud their judgment. Having said, I think a quick movement to an incremental approach is at least as risky as waiting for a few days, even weeks to determine if we can round up the votes (by getting groups who are increasingly, and perhaps constructively for us, fearing that nothing will happen — AND lobby the House Dems hard). (Frankly, between you and me, I suspect that if we fail to do go for the Senate package, we may well not get any bill enacted this year, no matter how hard we try).

So, my initial advice (and I haven't talked to Rahm in a couple of weeks) is to step back and see if the increasing perception that we may get nothing haunt people who were being difficult in the Senate-House negotiations to largely accept the Senate bill. Use the SOTU to focus on the consequences of inaction in more compelling ways to fuel this sentiment a bit more. If we need to make some relatively small changes to secure final necessary votes, I would argue to limit them as much as possible. Make the Senate leadership guarantee to the House, though, that these policies will be passed by the Senate in a reconciliation package. However, add them as riders to a hopefully much more popular economic development/jobs reconciliation bill. In other words, don't make the necessary changes visible; hide them on a bigger vehicle that has to be enacted in any case.

It's the second half of the email in which Mr. Jennings lays out his suggestions for a "weaker tea" incremental package of reforms...but only if TPTB aren't willing to put their necks on the line for the larger ACA as a whole under the circumstances:

Having said all the above, of course, I am more than willing to help produce and sell an incremental package if all the powers that be conclude we have no other option. I just have to be honest with you about my assessment about where this now stands and could go. If we go that route, the policies should be designed to be politically popular, policy viable, administratively feasible, relatively inexpensive and paid for, and easy to sell to outside groups/experts who would validate as a step forward. It should be a series of policies that are popular enough to be able to conceivably attract 60 votes, but under any circumstances not vulnerable to failing to get at least 50 votes in a reconciliation context. They must be relatively easily understood and simple to communicate. Options include (and can be stand alone or collective) and probably should be designed to cost less than $200 billion over 5 years (because the reconciliation bill sunsets provisions after this period of time):

  • 1) Some simple insurance reforms that would not mess up the market — things like banning retrospective rescissions, the elimination of pre-existing conditions for children, the extrication of lifetime caps, and the extension of dependent coverage offerings for kids;
  • 2) A Federal grant and waiver program to get states to do comprehensive reform themselves (with some consumer protection minimum requirements). Senator-elect Brown would have a hard time opposing this (since he said states should be supported to take the lead — like MA did);
  • 3) A parents mandate (individual requirement) to cover their kids with the help of tax credits (and help from Medicaid/CHIP) to obtain private insurance coverage OR through a state public program (like Medicaid);
  • 4) A Medicaid or CHIP expansion to parents;
  • 5) A reinsurance payment system for certain targeted populations OR federally-sponsored high risk pools to cover uninsurable populations. This might be a policy that is designed for the 55-64 population.
  • 6) The provision of a targeted small business tax credit might be a popular provision, (though it probably wouldn't get much new coverage);
  • 7) Something more for seniors — perhaps a further down-payment on the Medicare doughnut hole coverage gap OR some modest steps toward home and community based care (and/or spousal impoverishment protections) (OR whatever AARP will sell and give us cover for). NOTE: Remember, the seniors disproportionately vote in mid-term elections and hate health reform more than any other cohort by far;
  • 8) Something on prevention/wellness — maybe the mandatory Trust Fund down-payment
  • 9) Some "game-changer" delivery and financing reforms that can be argued to secure value over volume and quality over quantity. This would probably include the Orszag-loved Independent Payment Assessment Board (IPAB); and
  • 10) Some specific offsets to pay for the bill, primarily through cherry-picked and downsized savings from old packages; mostly this would come from Medicare; Medicare managed care programs would be biggest contributors.

We probably could not do all of these provisions, even downsized. Moreover, we would like to narrow the message perhaps to first steps on insurance reforms, kids, seniors, and small businesses within a reformed delivery system that focuses on prevention/wellness.

At any rate, this is probably more than you want, but I wanted to give you my sense of the state of play. Hope you find helpful. Always at your service. If you want to talk re this, don't hesitate to give me a call on my cell

- Best. Chris

Now, it can be argued that the final version of the ACA ended up being somewhere in between the two, but that's not the point. The point is that Jennings is offering his best assessment of the situation and some thoughtful recommendations, none of which can in any way be considered to be a "secret plan" to "destroy health reform".

UPDATE: The good news is that Mr. Fang has publicly apologized for his mistake and deleted the original tweet:

My apology to @neeratanden for attributing an email to her on Fri night foia dump, many neera emails in that dump but one wasn't hers

— Lee Fang (@lhfang) February 28, 2016

The only problem here is that Fang still doesn't seem to grasp that even if Tanden had written the original email...so what? If anything, as Harold Pollack noted, Jennings's email just demonstrates how gutsy it was of the Obama administration to push through the ACA anyway.

UPDATE x2: OK, shortly after his apology this morning, Fang posted the link to the correct email from Tanden to Hillary Clinton from the same day. Fair enough...except that, just like Jennings's email, all Tanden's message does is prove that she was pushing for the full ACA bill, not the stripped-down "Plan B" option:

Essentially, as has been reported, there are two options on the table:

Option 1: House pass a bill through reconciliation that contains the tax and spend portions of the conference agreement that we had basically forged, alongside the Senate bill. The Senate then passes the agreement through reconciliation, with a majority vote. The problem here is that there is great fear in the House that they will only end up with the Senate bill and the Nebraska deal is a killer. Coakley has argued that the Nebraska Medicare deal hurt her and people in the House have internalized that argument. In addition, there's an abortion problem. We only had one vote to spare with the House bill with Stupak's restrictions, and the Bishops have opposed the Nelson deal on abortion in the Senate side. One could ask why they would oppose health care for 30 million people based on the differences between the House and Senate abortion amendments - which are pretty darn close - but that is definitely a problem and could cost a few votes. Which would mean getting people who voted against the House plan to vote for it. Now even a month ago, there were House moderates who supported the Senate plan over the House. For example, I talked to Stephanie Herseth Sandlin and she told me she would support the Senate bill (this was before the Nelson deal). But now, after Massachusetts, converting a no vote to yes is incredibly difficult, if not impossible.

Option 2: Strip down the bill to its most popular elements, including insurance reform and cost containment, with little or nothing on coverage. Some folks seem to think that if we do cost containment, then we have fulfilled our promises. The substantive problems with this approach are, as you know, that we can't do guarantee issue/no pre-existing condition exclusion without covering lots more people. If we do, costs will likely rise for everyone, which has pretty much happened in states with community rating as insurers just pass on the costs. There are political problems with this, because its so far from what the President offered, but even leaving that aside, I personally do not understand who is the 60th vote for that approach. I do not understand why Snowe will vote for this - the political pressure on her to vote no will be extraordinary. And the fact is that the Senate bill that was on the floor in December met her substantive requirements - it had no public plan, but was more generous on subsidies. And yet, she just kept telling us to not rush things. I mean, I'm with Harry Reid who has said it was a waste of time to spend so much effort courting her. I hope I'm wrong, because otherwise, I'm not really sure what to do.

There seems to be some thought to let the caucuses take their temperatures and come to the realization that option 1 is in their best interest. Because really, they should understand that they have all voted for this bill and the Republicans are going to run against them on the bill regardless, and if it fails, they have no counterargument. If they pass it, they will look like they can actually govern and will have at least something to say about the bill that is positive. Maybe they need to come to that realization on their own, because there is a lot of anger at the White House for making them spend a year on this bill that is so clearly unpopular. So that seems to be why we're waiting. In the meantime, we are working on Option 2 in case it comes to that, and we hope that Snowe or Collins or both will go along. There may be a secret strategy to get them, but I certainly don't know it. Or maybe people will come to Option 2 sooner and it will move quickly

But then potus floated it in his interview with ABC yesterday and then Baucus is pushing hard for passage of the Senate bill, as are others. And really not unexpectedly. But obviously, we have the House problem.

In the meantime, as we wait, these things can fly out of control and people on the Hill are pretty pessimistic. They are running through these scenarios too. And obviously, everyone is freaked out. Polling is horrible out there - Lincoln is behind as are other Democrats, like Specter.

The one good sign is that labor and Senator Conrad were both agreeing on using reconciliation for cleanup of the Senate bill. But that was yesterday.

In terms of cost containment ideas that are palatable in a skinnier bill, we are focused on the following:

  • Administrative Simplification
  • Center on Innovation in Medicare--where Medicare pushes innovations like chronic care management, accountable care organizations
  • Bundled Payments - where Medicare promotes paying for a disease treatment, rather than each point of service
  • Quality Reporting - requiring hospitals to report -Hospital Acquired Infections - lower payments
  • Readmissions - reduced payment for avoidable readmissions

These are the ideas we're putting in the Option 2 plan. [You had quality reporting, chronic care management, administrative simplification (through electronic records) and something close to Hospital Acquired Infections in your health care plan; we also talked about innovations in payment systems to reward quality but were pretty general, though hinted at something close to bundled payments.]

The problem is CB0 is not giving much credit for each of these items. And they list prevention as a cost. The big cost reduction items that score are the excise tax on high cost health care plans (e.g. the Cadillac tax) and the Independent Payment Advisory Commission (what used to be known as IMAC which creates processes to streamline cutting Medicare). The excise tax is not going to happen in a scaled back bill because labor will go ballistic. And the House hates the Commission. So you see the quandary on costs. We survived the campaign on using electronic records, chronic care management and prevention as our answers on cost control even though they would not have counted for big savers with CB0 so perhaps that doesn't really matter. In terms of actually paying for the $100 billion, we'd use mostly Medicare Advantage cuts.

That's pretty much the state of play as I know it. And obviously things are very fluid. I would not say I'm particularly optimistic. But you know my motto - expect the worst and be relieved/thankful when it doesn't happen.

The Massachusetts loss is so confoundingly stupid I don't even know how to wrap my head around it. I mean, there are no other races right now. I just do not understand what Messina/Gaspard, the DNC and the DSCC were doing over the last month. I heard Wed that she had a 40% chance of losing and sent up the alarm to everyone I knew. And it seemed like many people had no idea.

I assume Rahm will welcome ideas on strategy as well as substance. Because God knows we need both.

As you can see, Tanden and her team were "working on" the 2nd option...but only as a fallback position in case the 1st option fell through. For some reason, Fang seems to be under the impression that because Tanden was involved in putting together a Plan B, that automatically means that she must have wanted to strip the bill down to the bare bones, which obviously isn't the case at all.

Now, if Fang had simply made his public apology to Tanden, provided the correct link and left it at that, he still would have been wrong to characterize Tanden's position...but he had to make things even worse by being kind of a dick about it:

So many Hillary sycophants piling on bc I tweeted wrong link. Heres the Neera email released Fri floating "option 2" https://t.co/wna7D8PKUB

— Lee Fang (@lhfang) February 28, 2016

Sycophants. For calling attention to a factual error and a characterization error on his part.

When I called him out on that, he responded:

@charles_gaba I tweeted the wrong link to a real email. You wrote a post without checking. She clearly says she was working on Option 2

— Lee Fang (@lhfang) February 28, 2016

@charles_gaba I was at CAP at the time, most leadership sided with Rahm approach of stripping bill down. Thinkprogress sided w/Pelosi

— Lee Fang (@lhfang) February 28, 2016

Now, the "wrote a post without checking" part is a matter of timing confusion; I posted this story shortly before Fang's apology, and posted the first update above before seeing his link to the correct email, so that's just an honest misunderstanding. However, this business about "clearly saying she was working on Option 2" is, again, just plain silly. For that matter, his follow-up tweet explaining that he worked at the Center for American Progress himself doesn't support his case...all that shows is that, again, there was tremendous conflict and debate at the time about which route to pursue. I'm obviously thankful that Option 1 ended up squeaking through, but there was a reasonable case to be made for going the other way as well.

OF COURSE they were working on an Option 2. Frankly, they'd be irresponsible not to do so. I'm fairly certain that there was a Plan B for the Normandy Invasion as well. And the Moon Landing. Or, to stay closer to home, there were probably Plan B's for Social Security, Medicare, Medicaid and so forth. In fact, there was probably a Plan C, D and E for most of these things.

Just because you work on alternate options that hardly means you'd prefer them.

Assuming Lee Fang is supporting Senator Sanders (which is a safe assumption given his description of Hillary supporters as "sycophants"), does he really think that Sanders will accept absolutely nothing less than 100% universal (including undocumented immigrants), comprehensive (including abortion coverage (Hyde amendment?) and contraception coverage (Hobby Lobby/Little Sisters of the Poor, anyone?), no-deductible, no-copay single payer healthcare??

Judging from Fang's attitude, anyone who suggests that perhaps a Sanders administration might have to have an "Option 2" ready as a fallback position just in case they can't achieve every single element of the above description must be nothing more than betraying the progressive movement...a "sycophant", if you will.

THAT'S what inspired me to write this post, not the initial, understandable mis-link: The assumption that making contingency plans for the even that you might not achieve 100% of your goal must mean that you're out to "destroy health reform". I'm aware that Mr. Fang is a respected journalist, but even the best make mistakes, and I really think he's doubling down on this without reason to do so.

UPDATE x3: As an aside, I made a major omission myself here: I forgot to give the real hero of the ACA being pushed through credit: Nancy Pelosi. This was particularly boneheaded of me seeing how I was the one who organized the Daily Kos "They Throw Rocks, We Throw Roses" project which delivered over 2,600 red roses to Speaker Pelosi's office for her birthday back on March 26, 2010 to thank her for pushing through the ACA as it stands.

As I wrote at the time:

As a few of you may be aware, all this week I've been spearheading an effort to send Speaker Pelosi roses today, both to wish her a happy birthday as well as to thank her for her successful shepherding of the historic (if, admittedly, deeply flawed) health care reform bill through the House of Representatives.

Sometime this morning (no earlier than 11:00 am EST, I'm told; it could spill over to the afternoon),  2,616 roses should be delivered to the Speaker's Washington, DC office.

I'll be using this diary to post updates as they're available, but in the meantime, I thought you guys might like to read the text of the letter that should be accompanying the flower delivery.

UPDATE x4: Hoo, boy...OK, via a whole mess of Twitter back-and-forth earlier this evening, the gist of the fuss is this: Mr. Fang claims that the "Option 2" was essentially a smokescreen by Rahm Emanuel (while he was still Pres. Obama's Chief of Staff) which was never intended to be a real "Plan B" alternative to the ACA. Fang claims that Tanden was in on "the fix" and that the work she and her team did developing "Option 2" was essentially busywork intended to kill any significant healthcare reform. Ms. Tanden, needless to say, strongly disagrees and insists that she and her team worked hard to come up with some sort of viable "Option 2" to present in the event the ACA as passed didn't get through the gauntlet.

Personally, I'd say that's a hell of an ugly accusation for Mr. Fang to make (especially after he claimed that  was "smearing" him today), but whatever his other evidence, the actual emails he presents (both of them) seem to indicate otherwise...as both of them are trying to argue for the ACA as it was passed, not against it.

In any event, I'm not sure what the point of dredging this up 6+ years later is. These emails are a fascinating look into the "sausage making" process of Congress, but it's all water under the bridge now.

Besides, judging by this tweet by Mr. Fang, it appears that he and Ms. Tanden have a bit of an unpleasant history. I think...it would be best if I just leave it at that.